How to Appeal Denied Health Insurance Claims

Family caregivers stand a better chance of success if they know and follow the rules

En español | Filing medical claims is dull work that usually pays off. But, sometimes, it’s just dull. When Medicare, Medicaid or insurance kicks back a claim or request, it can add angst to the already stressful job of caregiver.

“Denied” sounds final and sometimes it is, but it may be just a way station on the road to approval.

Insurance plans, Medicare and Medicaid all have appeals processes and people to walk you through them — but you have to follow their rules. The first is: Don’t procrastinate. Some plans and providers turn unpaid bills over to collection agencies after 60 days. File Medicaid appeals ASAP. The most generous deadline is 90 days from the date the denial was mailed, but state deadlines vary. Check the rules for the patient’s state when the denial arrives. If you miss the deadline, you will have to justify a late appeal. The Medicare cutoff varies depending on if it’s Medicare A, B, C or D.

Steps to Take Before Starting an Appeal

If the service has been completed and the payment denied by Medicare, Medicaid or an insurance plan, do this before starting an appeal:

Ask the hospital or doctor’s business office for copies of the medical records.

Compare records with bills. The wrong code or date, a misspelled name, a digit off an account number or incomplete paperwork can be cause for denial.

If you find a discrepancy, report it to the billing office and ask that it be corrected and the claim resubmitted.

Ask for an explanation of any questionable charges.

If the answer is not satisfying, ask to speak with a manager.

If the problem is not in the paperwork, or if your loved one has been denied a medical service or treatment you believe is essential to his or her health, it’s time to appeal. Here's how.

skilled nursing, home health care or treatment at a comprehensive rehabilitation facility

If you, the patient or health care provider believe a delay in treatment, service, equipment or prescription drugs might worsen the patient’s condition or situation, ask that the appeal be declared urgent. If the plan agrees, it will be answered within 72 hours (24 hours for drug appeals).

Ask the plan sponsor for an exception. The health care provider who wrote the prescription must submit a declaration saying why the drug is necessary. If a delay might put the patient at risk, the doctor can request an expedited appeal by phone.

Unlike Medicare and Medicaid, private health insurers do not have a single way of doing things. If your loved one’s claim is denied, follow these steps.

Step 1. Call member services. Have the insurance card, patient’s birthdate, Social Security number and letter of denial in hand. Be prepared to get names and take notes.

Ask why the claim for the procedure, treatment or hospitalization was rejected.

If there’s a discrepancy between the insurance company and the provider’s billing office, request a three-way call with the two companies and you. If the mistake is clerical — a missing preapproval number, wrong code — the fix may be simple and quick.

Step 2. If the problem is that the insurance company doesn’t cover the service, ask them to provide the guidelines for what they consider medically necessary.

Step 3. If you and the doctor believe the service to be medically necessary:

Have the doctor provide a letter explaining why the service is essential.

Research the procedure or service. Reputable studies and scientific evidence that shows the procedure or service to be effective can help make your case. A good resource is PubMed.gov.

Step 4. If the plan is not persuaded by a doctor’s letter and the research you provide, ask the customer rep how to start a formal appeal. Follow instructions exactly.

Step 5. If, in the end, the denial is unchanged but you remain convinced that the verdict is wrong, contact your state insurance commissioner.

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